Quality & Operational Improvement Engineer - Clinical Documentation Improvement

The University of Iowa Health Care seeks a Clinical Documentation Specialist to improve the accuracy, clarity, and completeness of acute inpatient medical records. The role reviews documentation, clarifies records with providers, supports accurate coding and claims, and contributes to quality and safety reviews.

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Responsibilities

Establishes effective and collaborative relationships with members of the hospital community to improve accuracy and completeness of acute inpatient documentation, especially with providers, Health Information Management coding staff, hospital administration, and other patient caregivers

Demonstrate knowledge of MS-DRGs, APR-DRGs, documentation opportunities, clinical documentation requirements, and inpatient quality/safety metrics

Consistently attend huddles or rounds on units, as directed by department leadership

Provides consistent education on clinical documentation opportunities, hospital coding and/or reimbursement issues, as well as performance improvement methodologies to all members of the hospital community

Conduct record reconciliation and communicates effectively with hospital coding staff to assign an appropriate working DRG

Documents appropriately in the 3M© Clinical Documentation Improvement module

Demonstrates an understanding of the importance of capturing all potential secondary diagnosis for coding purposes

Maintains thorough and current knowledge of clinical care and treatment of assigned patient populations to critically assess appropriateness of documentation

Comply with departmental standards regarding attendance, documentation, departmental workflows, continuous quality improvement and statistics, departmental policies and procedures, and the Code of Ethics

Effectively collaborates and respectfully communicates with fellow CDI team members, the hospital coding team, and quality-driven workgroups to ensure appropriate CDI practices and accurate application of coding/documentation principals

Actively participate in office and/or intradepartmental committees

Performs other projects or responsibilities as assigned

Preferred

Experience with performance improvement methodologies

Experience improving and/or reviewing hospital quality/safety metrics

Experience with data mining and/or data analytics

Advanced certification (i.e., CCDS, CDIP, CPHQ)

Benefits

Paid vacation

Sick leave

Health, dental, life and disability insurance options

Generous employer contributions into retirement plans

Flexible work schedule between 8:00 AM and 4:30 PM, Monday through Friday

Eligible for 100% remote work after initial training and onboarding; remote work must be performed at a location within the state of Iowa

University research support, compliance, and core facilities services.

Iowa City, Iowa, US

https://research.uiowa.edu

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Qualifications

A bachelor's degree in nursing or a master's degree in nursing (MNHP or MSN), or an equivalent combination of education in a related field and experience is required

A current license to practice nursing in Iowa is required

Previous work experience (within the last 5 years) as a Clinical Documentation Specialist is required

Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire

Professional written and verbal communication skills are required

Demonstrates the ability to provide effective education in a variety of styles, including formal presentations

Proficiency with computer software applications (i.e., Microsoft applications) is required

Demonstrates excellent interpersonal skills with physicians, nursing staff, and interdisciplinary team members as demonstrated through written and verbal communication is required

Demonstrated organizational, time management and problem-solving skills are required

This position is not eligible for University of Iowa sponsorship for employment authorization

Experience with performance improvement methodologies

Experience improving and/or reviewing hospital quality/safety metrics

Experience with data mining and/or data analytics

Advanced certification (i.e., CCDS, CDIP, CPHQ)

Previous work experience (within the last 5 years) as a Clinical Documentation Specialist is required.

Must obtain CCDS (Certified Clinical Documentation Specialist) certification within 3 years of hire.

Required skills

Represents the skills you have, click on the tags, Clinical Documentation Improvement, Hospital Coding, Iowa Nursing License, Microsoft Applications, Performance Improvement Methodologies, Hospital Quality and Safety Metrics, CDIP Certification, CPHQ Certification

Preferred skills

Experience with performance improvement methodologies, Experience with data mining and/or data analytics, Advanced certification (i.e., CCDS, CDIP, CPHQ)

Experience

Mid level